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04/08/2016 8:54Ahi FAX 9528733112 f�0002/0004 <br /> Property address: 140 South Brown Road,brono,Mn Inspector inifials/Date= JS f 41s12016 <br /> (mm/dd/yYYY) <br /> 1. Impact on Public Heaith�Compliance component#1 of 5 <br /> Campliance criteria: Verificatipn method(s): <br /> System discharges sewage to the ❑ Yes � No � $earched for surface outlet <br /> ground surface� ❑Searched for seeping in yard/backup in home <br /> System discharges sewage to drain ❑ Yes � No ❑ Excsssive ponding in soii system/D-boxes <br /> tile or surface waters. <br /> - — ❑ Homgowner testimony(See Commants/explanation) <br /> System causes sewage bacicup into ❑Yes � No Q°Black soii"above soil dispersal system <br /> dwelling or establlshment. <br /> ❑System requires"emergency"pumping <br /> Any"yes"answ�r above indicates fhe ❑ Pertormed dye test <br /> system!s an imminent threat to puf�lic ❑ Unable to varify(See Comments✓ExplanaUon) <br /> healfh and safefy. <br /> _ ❑Other methOdS not IistOd(See Comm�nts/Explanatlon) <br /> Comments/Expianation: <br /> 2. Tank Integrity—Campliance component#2 of 5 <br /> Compliance criteria: Verificatfon method(s): <br /> System consists of a seepage pit, ❑Yes � No ❑ Probed tank(s)bottom <br /> cessp�ol, drywell,or leachinc�pit. <br /> ❑ Examined construCtlon records <br /> Seepagepits meeting%080.2550 may be ❑ �xamined Tank Integrity Form (Arraon� <br /> compliant rf aRowed I»locel ordinance. <br /> Sewage tank(s)leak below their ❑Yes ❑ observed Ilquld level below operating depth <br /> designed operating depth. � �� � Examined empty(pumped)tanks(s} <br /> If yes,wh€ch sewage tank(s)Eeaks: ❑ Probed outside tank(s)for"black soiP' <br /> Any "yes"answer a6ove indicates fhe � Unable t0 V2rify(Sea Commsnts/Explanation) <br /> system is failing fo protect groundwater, CJ Other methOdS IlOt iisted(5ee Comment.s/Explanation) <br /> Comments/�xplanation: <br /> 3. Other Compliance Canditions—Compiiance component#3 of 5 <br /> a. Maintenance hole cavers are damaged,cracked, unsecured,or appear to bg structurally unsound, ❑Yos" �No ❑Unknown <br /> b. Other is5ueS(elecvkalhazards,eec.)to immecilately and adversely impact publie health or safety. ❑ves" �No ❑unknoum <br /> "System is an imminent threaf to public health and safety. <br /> �cplain: <br /> c, System is non-protective of ground water fzar ofher conditions as determingd by inspector. p Yes" �No <br /> 'Systiem is fal!!ng tn protect groandwater. <br /> Explain: <br /> www.pca.state.mn.us . 551-Z96-6300 • 840-657•38b4 • m 651-282•5332 or 800-657•3864 • Available in aRternative formats <br /> wq-wwlsts4-37 • 3/lb/12 Page 2 of 3 <br />